This document provides guidance on evaluating patients presenting with gradual loss of vision. It outlines taking a history to determine factors like onset, progression, associated symptoms and medical history. The physical exam involves assessing visual acuity, the red reflex, visual fields and optic nerve/macula. Common causes of gradual vision loss include glaucoma, refractive error, cataract, diabetic retinopathy and age-related macular degeneration. Treatment depends on the underlying cause but may involve prescription lenses, medical management or referral for further evaluation.

1. Prepared by:
Muhd Ariff b Mahdzub
GRADUAL LOSS OF
VISION

2. Introduction
• Patients with gradual loss of vision present with
chronic, slowly progressive loss of vision which is
generally painless.
• Visual loss is usually bilateral, but may occur
asymmetrically, and happens over weeks to
years.
• Poor vision in one eye may only be noticed when
the patient closes the other eye, and thus may be
reported to be sudden in onset in some cases.

3. General History Taking
Gradual Loss Vision

4. • Patient age(younger/older)
• The nature of the problem
I. Unilateral OR bilateral
II. Painfull or painless
III. Blurred vision? (whole field, close,
distance or both).
IV. Restricted visual field? (often noted
following difficulties in driving/ daily
activity

5. • Progression:
1. Ask whether there has been a slow and
steady decline or whether there have been
step-wise drops in visual acuity, or
• Any associated symptoms. (eg: pain, redness,
or visual phenomena - eg, haloes or flashes of
light).
• Any precipitating factors (Specifically ask about
whether vision is better in the day or at night).
• Hx trauma

6. Medical history
Ask for systemic
conditions/duration/compliance to med
I. Endocrine/metabolic (Diabetes mellitus)
II. HTN
III. Hyperthyriodism
IV. hyperlipidimia

7. Cont.
• Medication - some drugs may be toxic to the
eye or precipitate acute angle-closure
glaucoma.
• Family history - it is helpful to know about
atopy, diabetes, thyroid disease, certain
malignancies and any hereditary syndromes.
• Social history -; eg, a metal worker

8. Physical examination

9. 1. Visual acuity. (Note whether this improves
using a pinhole)
2. Red reflex using opthalmoscope.
- Media opacity (appears black against the red
reflex) suggests a corneal, lens or vitreous
problem.
- Media clear, it is more likely to be a retinal or
optic nerve disorder.
Do a functional testing of visual field, pupils
(RAPD), optic nerve and macula
3. Use an Amsler grid to look for distortion of
straight lines - if present, this indicates serious
macular pathology and needs urgent referral.

11. Primary care assessment of patients
with gradual loss of vision

13. The common causes of gradual loss
of vision
Glaucoma Cystoid mascular oedema
Refractive error Diabetic retinopathy
Cataract Retinitis pigmentosa
ARMD (Age-Related Macular
degeneration)
Drug

14. Treatment
It is treated by prescribing suitable correcting
spherical convex lenses.
From: Basic
opthalmology 4th
edition, page 51